Essex Partnership University NHS Foundation Trust (16 011 081b)

The Ombudsman's final decision:

Summary: The complainants allege that the Council, the Hospital and the Trust made unsubstantiated allegations about their care of their daughter who has significant mental health difficulties and, at the time of the events of this complaint, was an inpatient in an adolescent psychiatric unit. They also complain that their daughter’s allegation of assault by a carer at the unit was not considered properly. The Ombudsmen have found fault causing injustice. The agencies have accepted the Ombudsmen’s findings and the recommendations to remedy the complaint and to improve future practice.

The complaint

The complainants, who I shall refer to as Mr and Mrs X, and their daughter, who l shall refer to as Ms X, complain that the Council, the Trust and the Hospital made a series of damaging allegations about the parents’ care of Ms X while she was in a psychiatric inpatient unit (referred to as the Unit).

A summary of the main allegations made about the parents were that:

they minimised Ms X’s health needs, they denied that she had an eating disorder, they undermined the treatment plan and they returned Ms X late to the Unit after home leave;

Mr X was verbally aggressive to staff, he was controlling, he assaulted his father in law and a carer at the Hospital in front of his children and there was an allegation of domestic abuse;

Mr X had an inappropriate physical relationship with his daughter and had made a sexual comment to a male carer from the Unit.

Mr and Mrs X and Ms X also complain that the Trust and the Hospital failed to deal with Ms X’s allegation against a carer properly.

The Ombudsmen’s role and powers

We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, we have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. We refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)

Remedies might include asking the organisation to apologise or to pay a financial remedy, for example, for avoidable worry caused, or the Ombudsmen might seek reimbursement of avoidable costs. They might also recommend the organisation takes action to avoid the same mistakes happening again.

When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that, during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.

If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

In accordance with our normal practice, the final statement will be sent to the Care Quality Commission (CQC) and Ofsted. We will also send a copy of the final decision statement to NHS England.

How I considered this complaint

I have seen the Trust and the Hospital’s files and obtained some documents from the Council. The Trust prepared a chronology of events which it had sent to the Council but which it had not initially been willing to disclose to Mr and Mrs X. However, the Trust agreed to do so at our request.

I have interviewed, in person, the Social Worker and her Manager from the Council and interviewed on the telephone the Chair of the child protection conference.

I interviewed the Consultant Psychiatrist (the Consultant) of the Unit on the telephone and the Ward Manager, in person, and spoke on the telephone to the Unit’s Head of Safeguarding, who has now left the Trust’s employment.

I spoke on the telephone to a Doctor from the Hospital and to the Safeguarding Advisor. The Safeguarding Nurse, who had the most involvement, has now left the Hospital’s employment.

I interviewed Mr and Mrs X and Ms X at their home. I have also seen Ms X at her current hospital placement.

I issued a draft decision statement which was sent to all the parties, including NHS England. I have considered the additional comments when reaching my final decision.

Relevant legislation

I have considered the following law and procedures:

Section 47 of the Children Act 1989 (the Act) provides that a local authority has a duty to investigate, where there is reasonable cause to suspect that a child is or is likely to suffer significant harm. Where a local authority has concerns about the parents’ care of their child, and is thinking of taking legal proceedings to obtain parental responsibility, it is expected to issue a ‘Letter before Proceedings’ to the parents, detailing the concerns and inviting parents and their solicitor (paid through legal aid) to a meeting to provide an opportunity to avoid legal action;

Under section 17 of the Children Act, a child is considered a ‘child in need’ if disabled or it is likely that his or her development will be impaired unless services are provided;

Working Together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children’ (March 2015) provides guidance about child protection investigations for all agencies. Local authority social workers have a statutory duty to lead assessments which should be holistic in approach. Where concerns are considered valid, a multi-agency conference will decide if a child is suffering or likely to suffer significant harm and whether a child protection or a child in need plan is required;

NHS organisations must cooperate with child protection authorities and professionals involved should have received training to ensure they attain the competences appropriate to their role. NHS funded health services should identify a named doctor and nurse for safeguarding;

Where there is an allegation that a staff member working with children has acted inappropriately, this should be referred to the Local Authority Designated Officer (LADO) in the area where the staff member works. Referrals should be made within one working day;

Suffolk Council Child Protection Procedures says that the social worker must provide a written report one day in advance before an initial child protection conference (although the Council has changed this to two days in advance). Social work reports must distinguish between factual information, observation, allegation and professional opinion. Details of the original referral should be included. The Chair of a child protection conference should be independent of the operational management for the case and should ensure that the child protection procedures have been followed. The Chair will consult professionals and aim for consensus but ultimately the Chair will make the decision, note any dissenting views and decide on the category for registration;

There are four categories for registration: sexual, physical and emotional abuse or neglect. The relevant category for this case is neglect . The Council’s definition of neglect is that there has been a persistent failure to meet a child’s needs likely to result in the serious impairment of the child’s health or development;

The Trust and the Hospital’s Safeguarding and Child Protection Procedures provide that staff have to consider whether a child could be at risk of significant harm (significant harm leading to impairment of a child’s health or development) as a consequence of abuse and/or neglect. The Trust advises staff to work co-operatively with parents unless this is inconsistent with ensuring the child’s safety;

The Mental Health Act 1983 (accompanied by detailed statutory Guidance) provides that, those with a recognisable mental health disorder, can be detained in hospital. Patients can appeal to a Mental Health Tribunal for discharge and the ‘nearest relative’ can also apply (Mr X is the nearest relative as the older parent). The Care Programme Approach is the process by which mental health services assess a patient’s needs, plan how to meet them and ensure that they are being met. Trusts must inform the child’s local authority children’s services after 90 days of a child being detained;

NHS England commissions low secure psychiatric beds (referred to as Tier 4 provision). It issues specification guidance so that low secure units know what is expected of them. NHS England is responsible for ensuring that the health commissioning system works effectively to promote and safeguard the welfare of children. It also has a role in monitoring the quality of care provided;

Obsessive compulsive disorder is an anxiety disorder formed of two parts; obsessions and compulsions. “An obsession is an unwanted and unpleasant thought, image or urge that repeatedly enters the mind, causing feelings of anxiety, disgust or unease. A compulsion is a repetitive or mental act that a person feels the need to carry out to relieve the unpleasant feelings brought by the obsessive thought. OCD can be distressing and significantly interfere with a person’s life” (NHS England definition).

The complaints procedure for councils and NHS organisations is set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009. Where complaints concern more than one responsible body, they should cooperate in handling the complaint and should establish who will lead the investigation, share relevant information and provide the complainant with a coordinated response.

Background to the complaint

Ms X became withdrawn while at her secondary school and there was concern about her low weight. Ms X had a period in her local hospital for investigation but no physical cause was identified for her weight loss. Ms X returned home under the care of her local Child and Adolescent Mental Health Service (CAMHS). The Psychiatrist from CAMHS requested additional support and finance for the family from the Council but this was not forthcoming.

A month later, Ms X was admitted to a residential child and family unit locally where there was also the opportunity for the parents to stay. The placement was week day only with Ms X returning home at the weekend. Ms X was exhibiting extreme behaviours around sleeping (refusing to sleep) and developed distressing night time rituals.

The residential unit requested social care support for the weekends because the parents were finding it hard to manage Ms X’s ritualistic behaviours. The Council decided that the case did not meet the threshold for intervention or for any other family support. A month later, health professionals again requested intervention from the Council but no further action was identified for social care as the Council considered mental health services were providing sufficient care and involvement. The Council did not regard Ms X as a ‘child in need’.

Ms X was then admitted to a hospital where she remained for ten months. During this time, Ms X was often restrained and was tube fed. She was diagnosed with treatment-resistant depression and with an extreme fixation on ritualistic behaviours with an irrational fear for her family if these rituals were interrupted. She also had difficulty in engaging in any meaningful way with staff.

Because of the parents’ concern that their daughter’s mental health difficulties were becoming more entrenched and she was not receiving appropriate help, Ms X was reassessed. The diagnosis was that Ms X had OCD, depression and anxiety with an eating disorder as an accompanying factor. The recommendation was that Ms X should be treated in an adolescent low secure psychiatric unit.

Admission to the Unit

The Consultant and the then Clinical Psychologist from the Unit went to visit Ms X at the hospital. Ms X indicated with a nod that she was willing to be placed at the Unit.

Ms X was admitted to the Unit initially as an informal patient (voluntarily). Following an assessment, Ms X was detained at the Unit under section 3 of the Mental Health Act to “treat low mood, ritualistic behaviours and a reluctance to sleep”. Her low weight, at this stage, was not the focus of intervention as it had been at the previous hospital. Section 3 of the Mental Health Act enabled treatment to be provided and, while consent is preferred, clinicians can provide treatment without consent where considered in the patient’s best interests. Throughout Ms X’s time at the Unit, the Consultant assessed Ms X’s capacity and he had concluded that she did not have capacity to consent.

Mr and Mrs X agreed to attend family therapy sessions with the Family Therapist at the Unit. They say that the Family Therapist did not explain to them how information obtained from these sessions might be used. They assumed, however, that the sessions, which covered personal matters between themselves, were confidential and would not be disclosed. Notes of family therapy sessions were placed on Ms X’s clinical files and therefore were available to carers at the Unit who were entitled to access Ms X’s records. Later, when the Unit made a safeguarding referral to the Council, it disclosed some of the information from these family sessions.

Ms X’s ritualistic behaviours happened all the time but were most pronounced at night time and were designed to ensure that she stayed awake. By this stage Ms X had not slept on a bed for nearly a year and attempts to make her do so were unsuccessful. A bean bag was provided instead.

Six months later, Ms X had her first admission to Hospital because of concern about possible croup (severe coughing). Ms X became very anxious and the plan to keep her in for more observation was dropped as a result. Ms X returned to the Unit the next day. Mr and Mrs X asked whether their daughter was getting enough at mealtimes to “make any significant difference to her increasingly frail form”.

Ms X had a second admission to Hospital. The Hospital dietician considered her diet was too dependent on fluids and a different meal plan was devised. Ms X returned to the Unit. The parents asked about Ms X’s meal plan and about the use of a food supplement, which they agreed was appropriate, but was having an unfortunate consequence in that it ‘bulked’ out her stomach and reduced her appetite for the next meal.

Mr and Mrs X wrote to the senior clinicians: “We have never agreed with the concept of snacks making up for carbohydrate offered at mealtimes … we understand meals to be less than we would normally give Ms X and are still sketchy on the details of Ms X’s main meal of the day”. Mrs X made suggestions about what should be included on Ms X’s meal plans based on what she knew her daughter liked to eat. It is not clear if the Unit took up her suggestion.

The Unit tried ‘exposure therapy’ (recognised treatment for OCD). But Ms X’s distress was significant and, after two weeks, this therapy was stopped.

At a meeting, which took place regularly at the Unit, it was agreed that the Clinical Psychologist would undertake an OCD assessment, observe Ms X’s behaviours during one night shift, provide guidance to the staff on management of OCD and a dietician would be involved because of Ms X’s continued weight loss.

There was a meeting at the Unit lead by the Consultant, referred to as a reformulation meeting. Professionals noted that the family were very stressed, that weekend leave could be difficult and therefore should be reduced to one day instead of both days. Concern was expressed about the parents’ relationship and that they required some education as to how they may inadvertently be contributing to the maintenance of Ms X’s OCD.

Ms X had a home visit to her parents. Mr and Mrs X say that these home visits had gradually deteriorated because Ms X became very distressed at return times to the Unit given her desire to be at home. It is clear from the records that Ms X wanted to be at home rather than in hospital. Mr and Mrs X were always open with the Unit about their difficulties in returning Ms X to the Unit and about the difficulties in managing Ms X’s behaviours at night time.

Mrs X says that she had called the Unit some hours before Ms X had to return to the Unit. When she was not back at the allocated time, the Unit’s carers called the parents and they spoke to Mrs X. Mrs X explained that her daughter was refusing to return. Staff could hear Ms X shouting at her mother. The parents say, at this stage, Ms X was extremely agitated and the Unit would have heard this.

Mrs X called the Unit back to say that Ms X had taken a razor and that her younger child, Child B, had wrestled with her to remove it. The Unit’s carers stated that they could hear Mr X shouting. They said they would call the Police if, in 10 minutes, Ms X was still refusing to return. The Unit carers did call back. Ms X was still refusing to return.

The Unit staff called the Police who went to Mr and Mrs X’s house. But, by this time, Mr X had left with Ms X to return her to the Unit. The Unit’s carers recorded, in their notes, that the Police had said to them that they were worried about the family environment and the ‘abuse’ towards Mrs X by Ms X and Mr X. However, the Police made no referral to social care, which they could have done, if they were concerned.

Mr X emailed the Consultant about the events at the weekend and about the general climate at the Unit. The Consultant agreed that the Clinical Manager would investigate their concerns and reply to them. Mr and Mrs X say that they received no letter from the Clinical Manager.

Mrs X spoke to one of the Unit’s carers explaining the anxiety exhibited by Ms X when returning to the Unit and that Ms X responded better to her father. The Unit’s notes referred to Mrs X alleging that there were ‘secret trysts’ between Ms X and her father. Mrs X says she does not recognise that term and had never said that. All she had referred to was that her husband was better able to persuade Ms X to comply with her treatment and other matters.

The Consultant spoke to the NHS Specialist Commissioners about finding another inpatient unit. He was concerned the Unit may not be the right placement for Ms X and that the parents were losing confidence in the Unit’s ability to treat her.

Ms X expressed frustration to the Clinical Psychologist at being on observation and that she was not being believed that she was not trying to lose weight. She agreed to continuing with the OCD assessment. The Unit’s carers emailed the Police to see if they had any safeguarding concerns. They received a response from the Police stating that Mrs X seemed less keen to have Ms X at home. The Police raised no safeguarding concerns.

Ms X was admitted to Hospital to review her meal plan. The Unit had advised 4,000 calories per day but Mr and Mrs X say the Hospital was critical of this and that Ms X never consumed more than 3,200 per day.

The Hospital carried out an ultrasound which revealed a midline mass in the pelvis and a small cyst. The Hospital felt it necessary to undertake a pregnancy test in case she had an ectopic pregnancy (when a fertilised egg implants itself outside of the womb). The Hospital say that Ms X verbally consented to this and this is recorded in the nursing notes “discussed BHCG testing. Agreed”. The Hospital say that consent was not required.

Ms X says that she was asked to do a urine test; she was not told that this was a pregnancy test. Had she known, she would not have consented because she knew she could not be pregnant. The Hospital subsequently decided that the mass was possibly faecal loading (a large volume of faecal matter causing an obstruction in the bowel).

The Unit’s Ward Manager told the Unit’s Head of Safeguarding “that the Hospital have queried with us about Ms X being abused and they wondered if she had had an ectopic pregnancy”. There is no record in the Unit’s records as to who, from the Hospital, had raised this query. The Hospital says it has no evidence that this comment was made and it is not recorded in its nursing notes.

At the next meeting, the Unit’s carers highlighted that, despite Ms X eating all her meals and additional calories, she had not been able to gain weight. By this stage, Ms X was dangerously underweight. The Unit’s carers noted that Ms X was often in discomfort and the Unit was concerned that there may be a physical reason for Ms X’s low weight which had not, as yet, been detected.

The Unit’s Ward Manager contacted the Police again asking for more information because the Unit had to decide whether to allow Ms X to have home leave. The Police said that they were not aware of domestic violence and that they had the impression that Ms X was very much loved by both parents but that her behaviour caused them difficulties. At this time, Mr and Mrs X were unaware that reference had been made to domestic violence by the Unit.

The Consultant spoke to Ms X. She expressed concern herself about her weight loss and said that she was complying with the meal plan. The Consultant met Ms X with her parents. He noted the parents encouraged Ms X to discuss her issues with him and that Mr X comforted his daughter when distressed. The Consultant and the parents agreed that Ms X required tube feeding.

The Unit’s Clinical Psychologist observed Ms X eating a cake but he reported that he had seen her put some tissue in the bin in which she had wrapped up some of the cake. Ms X became distressed when asked about this and stated she was tired of being ‘accused of things’. It was decided that Ms X had to be placed back on closer observation. Later some laxatives were found in Ms X’s room which she said were not hers, and that they may have belonged to another patient.

The Unit’s Ward Manager told the Unit’s Head of Safeguarding that laxatives had been found in Ms X’s room, saying that the parents had given these to her because the Unit did not stock them. The Unit’s Ward Manager thought also the parents had given her some paracetamol. They had because Ms X was in pain but they thought she might have taken more and they reported this to the Unit. The Ward Manager was concerned that the parents “are undermining our work here and have a need to keep her ill”. He wondered about the need to complete a safeguarding referral but he wanted advice.

The parents asked for Ms X to be weighed because they were so concerned about her weight loss. They say the Unit was unwilling to do so. Later the Unit called an ambulance because Ms X was complaining of a burning pain in her stomach and her back, her blood pressure was very low and the nursing staff were worried that Ms X might have a cardiac arrest. She was taken to Hospital by ambulance.

Admission to Hospital

As Ms X was detained under the Mental Health Act, carers from the Unit had to supervise Ms X day and night. Ms X was placed in a separate room on the Hospital’s Ward. The Consultant says that he had been anxious, as were the parents, to rule out any serious illness which might account for Ms X’s continued weight loss.

The Consultant and the Hospital agreed Ms X should remain in Hospital until her weight had reached a certain level and that tube feeding would be necessary. A Hospital Dietician noted that the Unit’s carer was not enforcing Ms X’s supplements.

A member of staff from the Unit removed Ms X’s water jug because the Unit claimed Ms X was deliberately ‘water loading’ to increase her weight. Because Ms X has very ritualistic behaviours, involving repeatedly placing objects in special places, this caused her enormous distress and she became very agitated. Hospital nursing staff could hear Ms X screaming so they went to her room. The Unit carer was asked to leave. Two different carers from the Unit arrived and remained with Ms X.

Ms X says that the Unit’s carer was asleep and woke up because of a call on his mobile. After the call, he moved her water jug. Ms X wrote a statement of events the next day: “I got very upset and distressed because my rituals got taken away from me and I felt I couldn’t cope. I was told I was being silly but I was so scared I was screaming and banging my head. (Carer) got really angry and violent to me. He started to grab me and threw me about the room-he slammed me down into the chair on a number of occasions really hard. I tried to get away from him and tried to push him off me with my legs then he punched me in my thigh”.

Ms X says that she had the feeling that nobody believed her allegation and she heard other Unit carers complaining about her because she had made an allegation. Ms X says she had never complained before about any incident.

A Hospital nurse informed Ms X’s keyworker at the Unit of Ms X’s allegation. She in turn spoke to Mrs X. Mrs X said that Ms X had also alleged that she had been restrained by five Hospital nurses. The Unit’s Ward Manager asked the Hospital to provide a written statement of events which it did. Mrs X said she had no reason to disbelieve her daughter.

At her next meeting, Ms X said that she found her meal plan too much to eat especially with her continued problems with her stomach (bloating, diarrhoea and constipation). She drunk a lot of water because she was thirsty, the room was hot and because she had headaches and she had been told to by the Hospital.

The Hospital completed a risk assessment. It found that Ms X’s challenging behaviour presented risks. The Unit’s Ward Manager telephoned the Hospital to ask for Ms X to be moved into the main area of the Hospital ward so to safeguard staff against complaints.

After an X-ray, it was decided that Ms X’s intestines were blocked. A Unit’s carer told the Hospital that Mr X was ‘seething’ as he felt the Hospital were not treating Ms X’s constipation. One of the carers from the Unit reported that the nurses at the Hospital were continuously monitoring the staff supporting Ms X and this made them feel uncomfortable. The Hospital reported to the Unit that their carers were seen with their back to Ms X talking to patients’ relatives rather than observing Ms X.

Mr and Mrs X’s email to the Unit and to the Hospital

Mr and Mrs X sent an email to the Family Therapist and to the Chief Executive of the Hospital. They stated that their daughter’s allegation had not been investigated and that “the lack of consistency means we now have doctors stating that Ms X is constipated due to either not eating or a lack of fibre and insufficient fluid intake, nurses restricting water on the Unit’s advice and others advising her to drink more or she will become dehydrated… and there is little support or acknowledgement of our needs”.

The Chief Executive of the Hospital suggested that he set up an investigation about the care received at the Hospital. Mrs X replied “It is absolutely our wish that both teams work together better rather than independently and involve us to best help Ms X”. The Hospital recorded this as a formal complaint.

Professionals’ meeting

Ms X’s keyworker told Mrs X that there was to be a meeting about Ms X’s allegation.

The Unit’s Head of Safeguarding says that she recalled concerns being raised with her, during the previous two months, by carers at the Unit particularly about Mr X. The Head decided to look at Ms X’s clinical files. She was concerned that the behaviours the carers had described to her were not recorded on the clinical files. The Head started a chronology to help her understand the case better and she made notes, alongside some entries. She suggested there should be a professionals’ meeting. She sent the chronology, which she started, to the Clinical Manager and asked him to complete it and upload it onto Ms X’s clinical files.

The Unit’s Ward Manager chaired the professionals’ meeting. The Head of Safeguarding took minutes, which were not on Ms X’s clinical files, but she had kept a copy and was able to provide these to the Ombudsmen.

The purpose of the meeting was “to share and explore future management of ongoing safeguarding issues regarding Ms X’s care”. The meeting recorded at the outset that a “number of staff had been subject of allegations either by Ms X or parents, none of which had been substantiated”.

The Consultant from the Unit joined the meeting later. He reported that the parents accepted Ms X had an eating disorder but that the parents believed that Ms X’s main problem was her OCD and her bowel functioning. He reported that Ms X had told him: “I do not want to look like this”. The Consultant said: “we have not understood what is driving this girl’s illness”.

The professionals agreed that there was no need to make a child protection referral to Children’s Services but it was appropriate to ask the Council for a child in need assessment with the family’s consent. Health professionals agreed to produce a chronology regarding the parents’ engagement, helpful and unhelpful, and that there should be a ‘tight’ plan between the Unit and the Hospital.

The Unit’s Head of Safeguarding recalled that some at the Unit viewed the family as protective and concerned about their daughter and others considered the parents were sabotaging the clinical care and there was a concern that Mr X could potentially be quite abusive. It is accepted there was a disconnect between the senior clinicians at the Unit with the carers who had the 24 hour responsibility to keep Ms X safe and ensure her care and meal plan was followed. The Unit’s carers did not consider the senior clinicians took their concerns seriously.

Neither the Hospital nor the Unit informed the parents of the discussion or outcome of the professionals’ meeting and they did not seek the parents’ consent to make a referral for a child in need assessment. The Hospital says that its professionals had not set up this meeting, so this was for the Unit to action.

Events after the professionals’ meeting

The Consultant wrote to Mr and Mrs X acknowledging a divided approach and that he would ask the Clinical Manager to follow up on some of their concerns. Mr and Mrs X say that they still did not receive a letter from him.

The Unit’s Ward Manager wrote to Mr and Mrs X about Ms X’s allegation. There is no record of this letter on the Unit’s files (Mr and Mrs X provided a copy for the Ombudsmen). He concluded that the Unit carer had been protecting Ms X from harming herself and the carer had assisted her to her chair and then Ms X ‘had thrown herself at his feet’. The Ward Manager said that there was no bruising. Mr and Mrs X say their daughter had shown the Unit carers her bruising.

Mr and Mrs X wrote to the Ward Manager about his investigation. They explained that Ms X had been restrained many times at the Unit and had never made a complaint before, stating “this suggests that something happened that went beyond normal expectations and certainly for a period of time after the incident Ms X expressed fears and anxiety that the defendant would return”. They were concerned that the matter had not been reported to the Local Authority Designated Officer (LADO). Mr and Mrs X copied this letter to the Head of Safeguarding and to the Consultant.

Mrs X, because she considered Ms X’s allegations had not been taken seriously, decided to make a direct referral to the Council’s Multi Agency Safeguarding Hub (MASH). MASH took down the details from Mrs X. Mrs X said that Ms X was tender on her left arm and right thigh, that the Unit carer had dragged her to her chair and slammed her down into the chair about four or five times. Mrs X explained that Ms X was frail and underweight.

The Council’s involvement

MASH decided that Ms X’s allegation met the threshold for a section 47 investigation. The matter was referred to the Children’s Team and the case allocated to a Social Worker. In accordance with procedure, the case was also referred to a Child Protection Police Officer. The Police then referred the matter to the LADO.

The Unit’s Ward Manager requested information from carers about an incident, some months earlier, when it had been alleged that Mr X had ‘made a pass’ at one of the male carers. This incident had not been recorded at the time by the Unit’s carers. The relevant carer emailed to say that this occurred during a particular week although, in the Trust’s chronology, it is stated that this event occurred on a day when Ms X was in Hospital and not at the Unit. Later it was clarified that the date was when Ms X was at the Unit.

The Ward Manager subsequently telephoned MASH. It is not recorded to whom he spoke. He made a note that he raised his concerns and that he was advised to make a referral. Later, the Head of Safeguarding emailed Mr and Mrs X expressing regrets at the parents’ dissatisfaction but citing ‘other significant allegations’ had arisen.

The Hospital asked the Council’s Children’s Services whether there were any concerns about the family. Children’s Services confirmed that they were investigating Ms X’s allegation and that the Social Worker and Police were due to visit Ms X that day. The Hospital informed the Unit’s Ward Manager. He came to the Hospital where he met the Social Worker. Later the Social Worker and the Police Officer saw Ms X.

The Unit’s Ward Manager told the Head of Safeguarding that he had sent a safeguarding referral to the Council but he not shared this with the parents because Mr X would coerce the family and he had threatened to remove Ms X from hospital.

The Multi Agency Referral (referral form)

The Ward Manager said that he had never completed a safeguarding referral form before and he was given no advice.

The referral form was undated and stated: “Ms X has been at Colchester Hospital … to address her physical health and low weight. In this time, she has not gained weight and staff have heard both parents tell her that she doesn’t need to eat her snacks suggesting that they are sabotaging treatment plans. The father insists that his daughter has a physical health problem and not an eating disorder despite a (previous) hospital and Colchester Hospital finding no organic causes for her low weight and ongoing constipation. Father particularly disrupts treatment plans”.

The Ward Manager mentioned Mrs X’s reference to ‘secret trysts’ between Mr X and his daughter and that Mr X made a sexual pass to one of the Unit’s male carers, witnessed by Ms X. He reported occasions when Ms X had sat on her father’s lap inappropriately. Personal information about Mr and Mrs X was also included on the referral form which could only have been obtained from the family therapy sessions. The Ward Manager says that the Unit’s Family Therapist talked to him about his sessions with the family.

The Ward Manager did not discuss the referral with the Consultant because he had understood from the Trust’s procedures that everybody had a responsibility for safeguarding and he did not need to discuss this with senior management.

The Consultant confirms that the Ward Manager had not spoken to him. The Trust had a specific form which staff should complete to record safeguarding concerns. There were no such forms on Ms X’s file. The Consultant would have expected staff to discuss with him a safeguarding referral but the Trust’s policy allowed staff to make referrals without consultation with senior clinicians. It was right staff were alert to the possibility of abuse within families and Mrs X had raised a concern about the exclusivity of her daughter’s relationship with her father. But the Consultant considered this was a manifestation of Ms X’s mental health illness.

When the Consultant did eventually see the referral form (sent to him by the parents after the initial child protection conference), he says he was concerned about the inaccurate medical information. He had not had any safeguarding concerns about the parents and recognised the difficulties for them in caring for Ms X.

The LADO’s involvement

The LADO met the Unit’s Ward Manager and the Council’s Social Worker and her Manager. She specifically asked the Ward Manager for details of previous allegations from Ms X to which he had referred to at the professionals’ meeting. The LADO advised of the importance of allegations requiring evidence. The Social Worker said that she had asked for health chronologies for this purpose.

The LADO spoke to Mrs X and to the Unit’s Head of Safeguarding. The Unit’s Head of Safeguarding told her that Ms X’s allegation had not been referred to the LADO because Ms X had retracted the allegation. Ms X says that she had never retracted her allegation. The LADO suggested that references to Mr X’s relationship with his daughter may be a father comforting his child, nothing more.

Events after the submission of the referral form

The Social Worker says that she became involved initially because of Ms X’s allegations. However, the health professionals from the Unit and Hospital then raised concerns with her about the parents. When the Social Worker received the referral form, she says her first thought was, given the level of identified risks, why had the Unit not made a safeguarding referral earlier. As the referral form was given directly to the Social Worker, and she was already undertaking a s47, there was not a separate strategy meeting to discuss this referral.

There was a meeting at the Hospital which the Unit’s Head of Safeguarding also attended. It was decided that Ms X required tube feeding because of concerns that her weight was dangerously low. Reference was made by the Hospital to the parents “obstructing care and not engaging in treatment plan. Parents reported by the Head of Safeguarding to be appealing Section 3”.

The Hospital and the Unit jointly agreed to move Ms X to another side room as her room required cleaning and to break the pattern of rituals. The move also brought Ms X closer to the Hospital’s Nursing Station, which the Unit’s Ward Manager had requested. Ms X became very distressed by the move and she had to be sedated. Mr X emailed the Unit’s Ward Manager expressing concern that Ms X had been moved and that it showed a lack of understanding by the Hospital of her ritualistic behaviours.

The Safeguarding Nurse from the Hospital telephoned Children’s Services raising “significant concerns regarding parents’ attitude towards Ms X’s health care, today after sedation the Hospital reported that Ms X’s father has been abusive about the incident”. The Council told the Hospital it could not assist because Ms X was in their care. Advice was given to act in Ms X’s interests, ideally in discussion with the parents. Later, the Unit’s Consultant asked Mr X to tell Ms X that she would be tube fed and he did so. The Consultant approached Mr X because he considered he could persuade his daughter to accept tube feeding.

Mr X accepts that he was concerned about the move of his daughter to another room because it was badly managed and caused his daughter avoidable distress. The Hospital says that Mr X was verbally abusive and intimidating towards the Unit’s carer and to the Hospital Matron. Mr X denies this.

Ms X’s grandparents also visited that day. Ms X absconded from her room and subsequently from the Ward, the parents say because she was distressed by not being able to use the bathroom without being observed. Mr X later found his daughter and brought her back to the Ward. The maternal grandfather alluded to the fact that it was Mr X’s fault that Ms X had wandered off the Ward and also Mr X’s fault that the colonic irrigation had not happened as planned. Mr X went to punch the father in law but did not strike him because the Unit carer came between them. Both Ms X, Child B and Mrs X witnessed this. Child B became distressed. The Hospital called the Police reporting that Mr X had assaulted the grandfather and the Unit ‘s carer.

Afterwards the Hospital’s Safeguarding Nurse and the Acting Head of Children’s Nursing spoke to the Unit’s carer. The carer described the incident as an accident and said Mr X could normally be ‘controlled’. The Hospital Safeguarding Nurse felt that this was a worrying response from the carer.

The Safeguarding Nurse spoke to Mrs X and the maternal grandmother. The Safeguarding Nurse recorded: “the maternal grandfather had explained the family were under stress and this explained the incident but I advised that it was an ‘assault’. The Safeguarding Nurse asked Mrs X if Mr X had hurt her; Mrs X did not reply. The grandmother said he” could get fired up” (although in another document it is said Mrs X said this). The Safeguarding Nurse recorded that Mrs X referred to Mr X being violent once in the past in front of the children.

The Hospital asked the Council whether it was permissible to allow Mr X to visit his daughter. The Social Worker’s Manager told the Hospital it was for the Hospital to decide because the Council did not have any additional information that “would indicate he is unsafe to Ms X”

The Hospital’s Safeguarding Nurse emailed the Social Worker; she felt Mr X: “was controlling and manipulating the whole situation and it is having a detrimental impact on Ms X’s health and compliance with treatment”. She advised a strategy meeting with a view to an initial child protection conference being held.

The Hospital Doctor says that it would not have been necessary for the Hospital to make a safeguarding referral simply because Mr X became challenging or questioning of his daughter’s treatment plan. Hospital clinicians and nurses understood that Mr and Mrs X were under considerable strain and that it was upsetting for them to see their daughter in such a poor physical and mental state.

However, the Hospital would have made a safeguarding referral, after Mr X‘s attempted assault of his father in law, if one had not already been made by the Unit. This is because of the disclosure of domestic abuse to the Hospital Safeguarding Nurse and Acting Head of Nursing and because a physical assault had taken place in front of Ms X and Child B.

Strategy meeting

Two days later, there was a strategy meeting at the Hospital chaired by the Hospital’s Safeguarding Manager (the Hospital do not have a record of this meeting on their files). The Social Worker kept a note and has recorded that professionals agreed that the Unit would seek a placement at an eating disorder unit, health professionals would complete a chronology of significant events and the Police would investigate the concern regarding domestic abuse and Mr X’s assault. The Council agreed to arrange an initial child protection case conference and to ask Mr X to leave the family home until further assessment.

The Social Worker telephoned Mr X, telling him that he should not return home nor contact his children. She referred to wider concerns. Mr X was shocked and extremely concerned. He felt he had to seek legal advice, which he did, and he subsequently agreed to comply with the Council’s request.

The Council, based on the information it had to date, sent a pre-proceedings letter to Mr and Mrs X in which it threatened to commence legal proceedings to take Ms X into care. The letter stated:

‘“the parents were undermining the health care plan, taking food that is not on her meal plan and telling her that she can miss meals; that when Ms X was allowed a home visit, the parents refused to return her and that they did not understand the seriousness of her health needs; that it was a worry that Mr X had demonstrated violent behaviour on the Ward and that there had been a disclosure of domestic violence; that the parents are minimising the concerns of health professionals and that Mr X had not taken responsibility for the incident with his father in law and that Mr X had demonstrated untoward behaviour to a staff member, had secret trysts with Ms X and encouraged an exclusive relationship’.

The Social Worker advised Mr and Mrs X to meet her and her Manager with their solicitor. The same day, the Hospital’s Chief Executive wrote to Mr X stating that, because of the risk he posed to the safety of patients, families and staff, he would not be allowed to visit Ms X.

The Social Worker emailed her Manager requesting an initial child protection conference. Her reasons were that Ms X had an eating disorder for which she had been hospitalised for three years, that health professionals were concerned about Mr X’s undermining of the treatment plans which had included attempts to have her treatment under the Mental Health Act stopped, that the parents considered Ms X had a physical illness which explained her low weight and they had suggested that Ms X could miss her meals. The Social Worker reported that the father had refused to return Ms X to the Unit after home leave and that Mr X was verbally abusive and aggressive towards staff at the Hospital. The Manager agreed to a conference to take place.

The Hospital recorded that Ms X was upset because she could not attend a meeting with her father. In a note, Ms X said: “I am finding things so hard this morning ... I need dad back nobody understands me just help”. The Hospital and the Unit agreed that Ms X would be discharged back to the Unit.

The Unit’s Ward Manager told the Social Worker that they had not told either Ms X or her parents of the plan to return her to the Unit because of concern that Mr X might try to remove his daughter. The Council advised that the parents should be informed, and the Police called, if Mr and Mrs X tried to remove their daughter.

That day Ms X was discharged from Hospital and placed in a different ward at the Unit. The records indicate that she was distressed. Mr X spoke to her on the telephone and encouraged her to remain calm and return to the Unit.

The Council’s child protection investigation

Mr X sent the Social Worker a copy of his letter to the Chief Executive of the Hospital explaining his actions and sending the Police’s ‘Refusal of Charge’ Notice. This Notice stated that there was insufficient evidence to prove that Mr X had committed an offence.

The next day, Mr X met the Social Worker and her Manager. The only record made in the Council’s files was that Mr X accepted the concerns about the incident with his father in law but he felt that this was a unique situation which had never happened before.

Mr X kept his own note. He says that he was given a ‘Working Agreement’ to sign at this meeting agreeing to leave the family home. Mr X did not sign this. He says that he explained the history of the case and that they had asked for help from the Council early on when Ms X was ill. The Social Worker referred to the Hospital nursing staff describing Mr X as ‘aggressive’; Mr X explained that the nursing staff were dismissive of his questions. Mr X says that the Social Worker told him that they had interviewed both children (Mr X says that Child B resented them coming to her school and said she wanted Ms X better and her dad back).

Mrs X telephoned the Social Worker. There is no record of this conversation in the Council’s files but Mrs X made a note.

She explained to the Social Worker that she was in shock after the incident at the Hospital and that she had been ‘grilled’ by the Hospital’s Safeguarding Nurse. She told the Social Worker that she had not referred to domestic abuse and it was not in the notes taken by the Police, a copy of which Mrs X had signed. The reference to an incident in the past was in relation to Mr X pushing over a table, in anger, in front of the children. Mrs X said that Mr X had never laid a finger on her or the children.

Mrs X corrected the notion that they did not appreciate Ms X had an eating disorder. They had supported tube feeding but Ms X’s eating disorder was intertwined with anxiety, depression and increasing OCD. Mrs X recorded that she spoke “passionately about the strain on us [the parents] watching Ms X deteriorate at the hands of those entrusted with her care and how we could not sit by and not make our feelings felt”.

MASH received a referral from the Police, stating: “It has been presented by health that her father was inappropriately protective which has led to the deterioration and was on face value neglectful. There was also a suggestion that the father would share a bed with Ms X and had told his wife that this was the only way she would settle … concerns have been raised that there has been some form of inappropriate sexual behaviour by the father towards the child”. The Police requested a joint visit. But, as a child protection enquiry was underway and a case conference arranged, it appears that this was subsumed within this process. It is not clear who made this referral to the Police but, on the balance of probability, it must have come from the Unit.

The Council arranged a family conference (this is to engage the wider family in helping to resolve concerns). There are notes of this meeting which are not entirely clear. But, it is recorded that the family had a good support network. The ‘worries’ focused on the recent incident at the Hospital and the pressure on the parents.

The Social Worker sought clarification from the Unit’s Family Therapist. He explained that Ms X was diagnosed with an Eating Disorder Not Otherwise Specified (EDNOS) when initially in hospital but prior to her admission to the Unit she had been diagnosed with depression and severe OCD. He said Ms X was being treated for an eating disorder and OCD but, because her health was so compromised, the priority was to keep her alive.

The Initial Child Protection Case Conference (the conference)

In attendance at the conference were a Safeguarding Police Officer, the Family Support Worker and the Social Worker and her Manager from the Council. From the Hospital was a Consultant Paediatrician, the Ward Sister and the Safeguarding Advisor. From the Unit, there was the Clinical Manager, Ms X’s keyworker and the Family Therapist. There was also Child B’s Assistant Head Teacher and the CAMHS Care Coordinator. There was an independent Chair.

There were three reports: one from the Social Worker, a report from the Hospital Safeguarding Advisor and a report from the Police. Mr and Mrs X say that they were given the reports for the conference 15 minutes beforehand. They did not have time to read them properly.

The Police referred to them attending the house when Ms X was late returning to the Unit; to the allegation against a carer by Ms X and to the more recent Police referral that Mr X was “inappropriately protective which has led to the deterioration (of Ms X) and was on the face value neglectful”.

The Hospital Safeguarding Advisor says that her report was brief due to insufficient time to complete it. She thought that she attended the conference as the Safeguarding Nurse’s senior was unavailable. The Hospital Safeguarding Advisor could not find a copy of the report on the Hospital’s records but she thought this may be because the report was hand delivered to the Social Worker on the day of the conference.

The Hospital report stated that:

“There is documentation that Dad stated that he did not believe Ms X has anorexia and that her condition is due to OCD and anxiety and that she does not have a problem with food. On another occasion Father stated that he would instruct Ms X to stop eating. On another occasion parents were observed to bring food in for Ms X which was not included on her diet plan. Staff have also reported concerns around Father and his behaviour whilst on the ward and his attitude to professionals. There is documentation relating to Father raising his voice and being aggressive towards professionals. The incident which occurred … whereby Father attempted to assault an elderly relative in front of the children resulted in him being barred from the hospital. Father’s comments following the assault are of concern: Father stated that he felt justified in his actions and would do it again. Following the above incident, Mother disclosed to the named nurse for safeguarding that Father had been physically violent towards her in the past, also in front of the children.

The report concluded that Ms X’s recovery was being prevented by parents’ behaviour and attitudes “and that her ill health would continue resulting in serious potentially life-threatening results if not addressed as a matter of urgency.”

The Consultant had written to the Social Worker the day before in relation to the Council’s pre-proceedings letter which the parents had shown him (at this stage the Consultant was unaware of the referral form). It is not clear whether the Consultant’s letter was disclosed directly to the conference members. It is not listed as such.

The Consultant wrote:

“Both parents have always accepted that Ms X has a mental illness and at a meeting at the Hospital they stated that ‘of course Ms X has an eating disorder … the parents asked a number of appropriate questions [regarding moving Ms X to a specialist eating disorder unit] and accepted that this would take place … [admission to the Unit] was not with the intention of treating an eating disorder. This has only come to prominence in the latter part of her admission…I am not in agreement with the statement that the parents do not understand the seriousness of Ms X’s health needs”. The Consultant said that the parents had, however, become too focused on her stomach difficulties.

The Council’s views at the conference

The Social Worker’s report for the initial child protection conference referred to Mr X’s ‘violent’ behaviour in the presence of his children, that Mrs X had talked of an incident of domestic abuse, that Mr X was minimising the concerns about Ms X’s mental health needs, that he had not taken responsibility for assaulting his father in law or a carer from the Unit, that he had acted inappropriately towards a staff member of the Unit and had inappropriately sent the Unit’s carer (involved in the incident at the Hospital) a bunch of flowers with his telephone number, and that it had been described that he had ‘secret trysts’ with Ms X.

The Social Worker stated that reports from the Unit and the Hospital should be taken into consideration. But there was no report from the Unit. The Social Worker recorded that Ms X had no disability or communication needs. She referred to Mr and Mrs X’s concerns about the inadequate care their daughter had received at the Unit and the Hospital, which was not considered a concern, “only in so much that it deterred them from taking on board the professionals’ concerns”.

The Social Worker reported that the Consultant and the Family Therapist said that the parents had consistently and positively engaged with care planning for Ms X, that they had remained involved in her healthcare and that, at times when Ms X became distressed, health professionals had asked Mr X to support them and Mrs X had been supporting staff in carrying out treatments in relation to Ms X’s constipation. The Social Worker acknowledged that there had been different reports from the professionals but it was felt that the Council needed further clarity about the concerns.

As a worry, the Council was concerned that Mrs X had retracted her previous allegation of domestic abuse, that there were concerns about Mr X’s exclusive relationship with Ms X, that he made a sexual pass to a male carer and, that he had a temper and was described as controlling. The Social Worker summarised her concerns: that Ms X had been out of education for so long, that the health professionals’ concerns had not been documented to the Council and that there was a danger of Ms X becoming institutionalised.

The conference members were asked to scale the risks between 0-10 with 0 being when people were very worried. Most professionals scaled the risk between 4 or 5. The Hospital scaled the risk at 2. Mrs X refused to scale and Mr X said the risk was 6.5 because there was a lot of contrary information. The Social Worker’s Manager stated there were more signs of safety than she had originally thought. She recognised that Ms X’s unwillingness to take direction from health professionals was concerning.

The Council recommended that both Ms X and Child B be made the subject of a child protection plan as did the Hospital. The Police, the Assistant Head and CAMHS thought Ms X should be the subject of a child protection plan but Child B should be the subject of a child in need plan.

The Unit stated: “We have struggled to agree as it is a very complex situation. Ms X’s difficulties have got worse in NHS care and not in parents’ care so we feel that the threshold has not been met for either child. Parents need help and support but we do not think they are responsible for what has happened”.

The Chair’s comments

The Chair could not recall the conference accurately from memory given it had taken place some years ago and he had chaired numerous conference since then. He had looked at the Council’s records. He did not recall seeing the Consultant’s letter at the time or the original referral form from the Unit. Mr and Mrs X say, however, that all the conference members had a copy of the referral form besides them.

The Chair’s main recollection was the concern around family relationships and how they might be adversely affecting Ms X and her recovery. The Chair says he has, in rare cases, recommended a decision was deferred while there were further investigations.

The conference minutes record the Chair’s summing up as follows: “The complexity around Ms X’s health needs is exacerbated as a result of high number of significant factors and events: disagreements over diagnosis, disagreement over treatment, whether the Health Care Plan has been consistent and whether this has been followed by the family and Mr X in particular. There is a further investigation by police on a member of staff for an assault on Ms X and a LADO meeting is taking place under [a neighbouring local authority] Procedures. In addition, Mr X had assaulted a member of staff who intervened in a physical dispute between him and his father in law all of which took place on the Ward, neither of whom proffered charges and there is no further police action to be taken in either case. Mr X has however been barred from the hospital and Unit as a result. The Unit will review this decision in the context of Ms X’s needs for contact with her father”.

The Chair concluded that the relationships between family members and parents, the domestic abuse allegations and concerns about Mr X’s relationship with Ms X were concerning. The Chair considered the chances of successful treatment were reduced in these circumstances and the dangers for Ms X increased.

By a majority, the plan was for Ms X to be subject to a child protection plan under the category of neglect but the criteria for child protection were not met for Child B and her wellbeing could be managed under a child in need plan. The conference decided a parenting assessment was necessary to consider the safety concerns more fully.

The Chair says the use of the category ‘neglect’ is broad and could cover concerns regarding relationships within the family adversely affecting a child’s development.

Events after the conference

The LADO concluded that Ms X’s allegation of physical assault by the carer could not be substantiated (that there was insufficient evidence to either prove or disprove the allegation). But the LADO stated that there was no evidence to support the comment that Ms X had a history of making allegations. Because the LADO was concerned about the way Ms X’s allegation had been dealt with, she visited the Unit to explain her role to staff and advise of good practice.

Within two weeks of the conference, there was the first Core Group meeting as part of the child protection plan. The Council noted that the information from health had been inconsistent.

The Police received a further referral stating that Mr X was interfering with the health plan. On the balance of probability, this must have originated from the Unit. After three weeks, the Police closed the investigation. Mr X stated to the Social Worker and the Consultant: “I don’t think any of you truly understand what this means. To share the pain and anguish every day”.

At the second Core Group meeting, the Consultant attended as did the Unit’s Head of Safeguarding. The Social Worker says that, at this meeting, the Consultant said he had had no safeguarding concerns about the parents. Had the Council been informed of this initially, the Social Worker says that it is likely the Council would have recommended that Ms X be made the subject of a child in need plan, rather than a child protection plan.

Ms X was moved to a specialist eating disorder unit primarily to regain the weight she had lost.

The Social Worker completed her parenting assessment, noting that neither Ms X nor Child B had made disclosures of concerns about the parental relationship. She concluded that Mr and Mrs X’s challenges of their daughter’s care plan stemmed from a position of advocating for what they believed were in her best interests. She referred to Mr X’s blunt and forthright approach and that, as a result, he could present as resistant to taking on board the views of others.

Mr and Mrs X responded to the assessment, stating that the allegations relied upon by the Council were based on factually inaccurate information, despite the evidence which they provided, and they asked why Ms X’s allegation was allowed to be confused with counter allegations against the parents.

At the review case conference, three months later, Ms X was placed on a child in need plan. The conference decided that there had been an improvement in the family relationships and the original concerns could not be substantiated.

Mr and Mrs X’s comments

Mr and Mrs X say they raised legitimate concerns about their daughter’s care regarding her meal plans, levels of observation, understanding of her OCD and bowel difficulties and the negative effect this had on her eating. Their experience is that some professionals at the Unit and the Hospital did not like to be challenged and both sought to deflect responsibility on to them.

Mr and Mrs X recognise that their daughter’s presentation was complex and this created difficulty in treating her. Eating at times had been a coping mechanism but also her disabling OCD behaviours and anxiety consumed much of her energies and focus. Without treating the OCD, they were pessimistic that Ms X would get better.

The division between the staff at the Unit and a disregard for their daughter’s mental health needs at the Hospital led to a breakdown of trust and collaborative working. They appropriately raised concerns with the Consultant, who acknowledged what they said even if it was not possible to resolve matters. They point to the fact that Ms X lost 16 kg while in the Unit’s care and that she put on a tiny amount of weight while in Hospital.

The inaccurate referral form from the Unit to the Council started a chain of events which resulted in unsubstantiated concerns developing with little regard to factual accuracy or accountability. Further, at no point did the Unit raise any such concerns with them directly. Professionals sought to prove the allegations, took matters out of context and cherry-picked information. Hearsay evidence became fact.

Mr and Mrs X feel aggrieved that Mr X was asked to leave his home. This request was made within days of the referral yet the Council did not have the evidence of the health professionals’ concerns, at this stage. Key information from the Consultant was also not sought promptly. Had it been, that might have made a significant difference. Moreover, the Unit’s Ward Manager submitted the safeguarding referral soon after Mrs X had referred Ms X’s allegation to the Council. To them this looks like a defensive action to detract from their concerns.

Mr and Mrs X are aggrieved that Ms X was made the subject of a child protection plan, and to add further insult, for neglect when she had been in the care of the Trust and Hospital for the past years. Further, at the initial conference, the Unit backtracked on its previous safeguarding allegations, recognising that Ms X had been in the Trust’s care for many years and her difficulties “got worse in NHS care and not in parents’ care”.

They consider that inappropriate remarks were made about the closeness of Mr X’s relationship with Ms X. The Unit’s carers and the Council misunderstood Ms X’s needs for comfort and reassurance and that she received this best from her father. Moreover, the Consultant had stated at the professionals’ meeting that her exclusivity with her father was a symptom of her mental health difficulties.

Finally, they say personal information from family therapy sessions was misused and disclosed in the health chronology without thought and the Trust had consistently denied them access to this. Mrs X says that the chronology was “riddled with sordid inference, far worse than I had anticipated”. She feels a sense of betrayal for “plundering our family therapy notes”.

Ms X’s comments

Ms X was angry when she learnt that she had had a pregnancy test without her consent.

She says that she hardly saw the Unit’s Ward Manager and he rarely spoke to her. Yet he made allegations about her parents. The Unit’s carers did not explain to her what was going on or why she could not see her father. Ms X has also raised concerns that carers were on their mobiles and she also heard carers complaining about her and about the fact she had made an allegation against one of its carers. She relied on her parents to explain. Ms X was very upset when she was not allowed to see her father. The Unit and Hospital did not understand how important her relationship with her parents was, and remains, so.

Nobody spoke to her about the incident at the Hospital except to try to convince her that her father had done something wrong.

Ms X says that her current hospital placement is most helpful in trying to help her with her OCD and that, if she had been placed here much sooner, her OCD may not have become so severe.

NHS England’s comments

They say that this was an extremely complex case with a number of clinical presentations which needed to be addressed. Finding the right placement in these circumstances was very challenging. They will ensure that the recommendations for the Trust are followed up.

Claimed injustice

Mr and Mrs X wish to be reimbursed the costs of seeking legal advice and other costs, during the child protection process, amounting to approximately £5,000 on the basis that this process was unnecessary and based on inaccurate, information which deliberately cast them in poor light. In addition, Mr X was asked to leave the family home because of unproven evidence made by the Trust.

The avoidable emotional impact and distress caused by the actions of all agencies has had a serious adverse impact on their wellbeing and on both Ms X and Child B. As a family, they were struggling with Ms X’s complex mental health disorder, and had done so for many years; the impact of this was difficult to explain or for others to understand. Mr and Mrs X fully appreciated that there were no easy answers in respect of treatment for Ms X. It is when some professionals blamed them and accused them of causing significant harm to Ms X that they became disillusioned and are now mistrustful of the system which was meant to help Ms X and her family.

They consider that all agencies failed to adequately reference or interpret Ms X’s prior history and medical records.

Analysis

Ms X has a complex mental health conditions and parents and professionals alike have struggled to find ways to help her. However, as Mr and Mrs X became more distressed and concerned for their daughter’s welfare, so their frustrations and grief became more acute. In addition, because Ms X was detained under the Mental Health Act, they lost the ability to exercise their parental responsibility in any meaningful way. Sadly, Ms X developed additional difficulties while in hospital, namely her loss of weight and the entrenchment of her ritualistic behaviours, and this added to the complexity of treatment.

It is right and proper for there to be professional curiosity and enquiry about the possible causes of children and young people’s harmful behaviours. There also needs to be communication between professionals on a need to know basis. But, some mental health disorders may not have an obvious cause and, in seeking to treat and help sufferers and in carrying out social care assessments of a child and parent relationship, it is important to bear this in mind.

Child protection enquiries are daunting for parents but are required to be undertaken. To help professionals deal with this duty, there are procedures and guidance to follow. This is to enable the difficult decisions and exercise of professional judgement to be made satisfactorily on a case by case basis and to ensure that the child’s welfare remains the paramount concern.

In addition, there are timeframes for child protection decisions to be made. Enquiries, therefore, must be focused and purposeful. Assessments should be informed by evidence and holistic in approach, addressing the child’s needs with their family and wider community. To do this properly, there should be some face to face contact with parents and children.

At the point of making a safeguarding referral, agencies need not necessarily be able to prove concerns. They are for the child protection agency to assess. But there must be some coherent evidence to give substance to suspicions. Otherwise ill-informed referrals and dubious claims will be made, often causing unnecessary distress. As Mr and Mrs X have stated, professionals appear to be able to “say anything with little recognition of consequence”.

Social work decisions, which lead to some interference in family life or to a child protection plan, rely upon properly recorded evidence that a child is or is likely to suffer significant harm. It is a basic tenet of good social work practice, and endorsed by the Family Courts, that councils must be able to prove what they allege when making welfare decisions in the best interests of children. To ensure that this happens, agencies should, wherever possible, be transparent with parents about concerns and be open to taking account of the information or interpretations which they may offer.

Findings - The Trust

The Trust accepts now that there is no evidence to suggest the parents undermined the health plan or minimised their daughter’s condition.

I too have seen no evidence to suggest that the parents dismissed concerns or failed to understand the seriousness of Ms X’s condition. The fact the parents challenged some aspects of their daughter’s treatment plan should not have been regarded negatively. As supportive parents, they were entitled to raise their concerns if they considered this necessary to safeguard their daughter’s best interests.

In respect of Ms X’s weight loss, the parents noted ‘her frail form’, and made suggestions about the meal plan. But they did not regard Ms X’s difficulties simply as ‘an eating disorder’. Moreover, they were also concerned that Ms X was often in discomfort and Mr and Mrs X wanted to ensure that there was no sinister reason for her weight loss. That was a legitimate concern.

Low secure adolescent psychiatric inpatient units care for young people, who are capable of causing significant harm to themselves. Professional anxiety, in these situations, is inevitably high.

As Ms X continued to lose weight and her ritualistic behaviours became entrenched, professional anxieties increased and the Unit’s carers started to build up an increasingly negative picture of the parents. Evidence to the contrary, for example the Police’s comments that there was no evidence of domestic abuse, or the Consultant’s explanation about the exclusivity of Ms X’s relationship with her father as a symptom of her mental health disorder, did not appear to be weighed in the balance.

The Trust has already upheld the following complaints: that the safeguarding referral should have been discussed with senior management; that Mr and Mrs X had not minimised Ms X’s health needs; that its carers did not always follow Ms X’s eating plan; that carers failed to make proper records of alleged safeguarding concerns and that Ms X’s allegation against a carer should have been referred to the LADO.

I endorse the Trust’s findings and, in addition, I find fault in the following matters:

The Trust told the parents that their concerns about certain matters at the Unit would be considered. They had confidence in the Consultant’s approach but they should have been offered an opportunity to discuss their concerns, in person, with the Clinical Manager, and should have received a written response, as they were told would happen;

The Trust did not tell Mr and Mrs X the outcome of the professionals’ meeting or seek their consent for a referral to the Council for a child in need assessment. By this stage, professional concerns were mounting and there was recognition that some additional help, under the child in need procedures, for the parents and Ms X may have been helpful. The Trust should therefore have discussed this promptly with the family and made a referral if there was consent to do so;

Alleged concerns about the parents were not always recorded, as acknowledged by the Trust. But, sometimes, when recorded, the information was not sufficient or did not identify the source. At some later date, information could be used as evidence to protect a child and therefore the source and details should have been properly recorded;

The Trust did not discuss its concerns directly and transparently with the parents and the justification that it could not, because the parents might try to remove Ms X, does not stand up to closer scrutiny. The parents always returned Ms X after home leave, even if, on one occasion, later than required (although there was a justified reason for this). Mr and Mrs X also supported Ms X being in hospital (despite her wish not to be) because they acknowledged their difficulty in managing her ritualistic behaviours. There were therefore lost opportunities for the Trust to be open about the concerns and to have face to face discussions with the parents and Ms X, however difficult those conversations might have been;

Most decisions about treatment and welfare at inpatient units are made by the team led by the Consultant. Carers and the Head of Safeguarding at the Unit would have known this and therefore the failure to discuss the safeguarding referral with the Consultant (already accepted by the Trust) was a significant error. The Consultant’s view was crucial and the fact that there may have been an internal disconnect between carers and the Consultant’s team, with differing views, was not an adequate reason to exclude senior management from such an important decision;

There was little guidance to the Unit’s Ward Manager about completing a safeguarding referral form. As a result, the referral form was inadequate and misleading. It was undated. It referred to a series of concerns and implied that Ms X was not gaining weight because the parents were sabotaging the meal plan. But the Trust had the fulltime responsibility for Ms X. It was not appropriate to deflect blame onto the parents for the failure of the meal plan which was primarily implemented by the Unit;

The referral listed a range of alleged risks without the evidence to support them as identified risks. For example, there was no evidence to support a concealed pregnancy; on the contrary the Hospital had ruled out pregnancy. There was no evidence to support allegations of fabricated illness, or physical or emotional abuse. Domestic abuse had also been ruled out by the Police;

The referral also ticked the box relating to alleged sexual abuse. But it provided vague evidence and it failed to explain the parents’ actions in the context of a child who refused to go to bed or explain the extent of Ms X’s obsessions and rituals. Moreover, the Consultant had already told those at the professionals’ meeting that Ms X’s exclusive relationship with her father was a feature of her mental health disorder but this was not referred to on the referral form, as it should have been;

The Trust failed to tell Mr and Mrs X, at the outset of family therapy, how the information they provided in these sessions might be used, in the interests of safeguarding, at some later date. Subsequently the Trust was unwilling to disclose its chronology, even when the Council, as child protection agency, advocated this. That made it difficult for the Council to deal openly with the parents and, when the parents saw the chronology, they then realised how their comments had been badly misconstrued or misreported;

The Trust acknowledged that Ms X’s allegation was not referred to the LADO promptly. But it is of concern that the Trust also quickly dismissed the allegation and referred, wrongly, at the professionals’ meeting, to the fact that Ms X had made unsubstantiated allegations previously. It is important that young people’s allegations are considered in the proper way and without hasty conclusions being reached before due process has been completed. Further, even if Ms X had made an unsubstantiated allegation previously, that should not lead to hasty conclusions about any subsequent allegation;

Having raised significant and numerous safeguarding concerns initially, the Trust then changed its mind and presented a completely different view at the initial child protection conference. The Trust should have provided a written report explaining fully why its allegations about the parents were no longer valid. It was not acceptable to withdraw concerns without clear reasons. That information was essential for conference members to reach a well-informed decision;

After the Trust told conference members that it did not support making Ms X the subject of a child protection plan, it continued to raise similar allegations about Mr X, in particular, and also restrict his contact with her;

Key documents were not put on Ms X’s clinical files.

I consider that, but for the above faults and in particular, had the safeguarding referral been discussed with the Consultant or other senior clinicians, on the balance of probability, I do not consider it would have been made to the Council and certainly not in its present form. And the lack of transparency and discussion with the parents about the concerns has meant a lost opportunity to develop a better understanding between the parents and the Trust which, in turn, could have led to a more collaborative and therapeutic working relationship in Ms X’s interests. It has also meant that the parents and Ms X have now lost trust in the agencies tasked to help the parents and Ms X.

The Hospital

The Hospital did not uphold Mr and Mrs X’s complaints. It has now given further consideration to their concerns.

The Hospital maintained Ms X’s weight and fully investigated whether there was a physical cause for her weight loss. That had been the Hospital’s prime focus. The management of Ms X’s mental health was the responsibility of the Trust. But the Hospital accepts that there was evidence of tensions between the Trust and the Hospital which added to the difficulty in maintaining a cohesive care plan between the Hospital and the Trust for Ms X.

The Hospital says that it was the collective opinion of its professionals that the parents focused on a physical cause for Ms X’s poor weight gain. But the Hospital now accepts that there is limited evidence of Mr and Mrs X obstructing the treatment plan, as alleged. There were also incidents which, taken in isolation, were minor but taken, as a whole, contributed to Hospital staff’s perception of Mr X as aggressive in approach. This explains why the Hospital considered it was sensible to contact the Police in anticipation of opposition to the proposed feeding plan.

The Hospital made no safeguarding referrals but it might have done so after the attempted assault of the grandfather and the information provided to the Safeguarding Nurse. However, the Hospital had no adverse remarks about the closeness of Ms X to her father. The Hospital cannot comment on how Ms X’s move to another room was managed given the passage of time. But the decision was made in conjunction with the Unit.

I find fault as follows:

The Hospital arranged a pregnancy test, according to Ms X, without her consent. The Hospital says it did not require Ms X’s consent. This is incorrect. Moreover, it should have considered whether Ms X had the capacity to make this decision and considered discussing its concerns with the parents;

The Hospital understood that Ms X did not have an ‘eating disorder’. This term may have been used as a shorthand way of describing Ms X’s condition in the Hospital notes. But the safeguarding report to the conference referred specifically to Mr X not believing that Ms X had an eating disorder. In turn, this led wrongly to the Hospital suggesting that Ms X’s recovery was being prevented by the parents’ behaviour and led to the Hospital recommending Ms X was made subject of a child protection plan;

The safeguarding report to the conference was sketchy and did not provide context in relation to the parents’ actions. Yet the Hospital had been instrumental in urging the Council to arrange a child protection conference and therefore it should have ensured it presented a detailed report about its concerns;

The Hospital (and the Trust) decided to move Ms X to another room. Because of her severe OCD, and obsession with objects having to be in the right place and in the right order, there should have been a discussion with the parents about the proposed move, and a plan devised with the parents about how best this should be done, if indeed it was considered essential to move Ms X. The parents had not lost their parental responsibility just because Ms X was being treated under the Mental Health Act and they should have been afforded a say on such a crucial matter;

The Hospital has no record or minutes of the strategy meeting which was held at its request. It is also not clear whether it has found a copy of its safeguarding report to the Council.

The Council

The Council says it did not arrange for a joint complaint investigation with health because it did not know at the time that Mr and Mrs X were making complaints to the Trust and Hospital. In future, the Council will be more alert to this possibility where a young person/child is also receiving health care.

The Council apologised to Mr and Mrs X that reports for the conference were not available on time. But, on other matters, the Council considered its actions were justified in light of its duty to investigate safeguarding concerns.

While not a part of our investigation, it seems to be an omission that the Council, when requested by Health early on, for additional support to the family, decided that this was not appropriate. It seems that Ms X should have been identified as a child in need much sooner and that this omission should be considered as part of the Suffolk Children’s Safeguarding Board’s current review.

I accept that the Council was presented with a very worrying description of the parents in the referral form and of possible risks to Ms X.

I consider the Council has been at fault as follows:

Some key discussions and contacts were not recorded on the Council’s system;

The Council should have discussed the referral allegations directly with the Unit’s Ward Manager, especially as the Council was concerned that the alleged risks had not been referred to the Council sooner and there were so many worrying risks identified. This might have helped to add clarity earlier in the child protection enquiry;

The Council did not seek out information from the Consultant at the outset. This may be because the Council did not know the structure and decision-making process within Tier 4 psychiatric inpatient units and had assumed that the Consultant knew of, and supported, the referral. But there was a lost opportunity here to obtain information from the Consultant who had key statutory responsibilities to Ms X and who knew her and the parents;

The Council has acknowledged that Mr and Mrs X did not receive the reports before the conference. The Chair of the conference should have checked that the Council had followed correct procedures and the parents had had this opportunity;

Verbal information provided by the Unit at the conference was at considerable odds with the information they had provided some three weeks earlier. It is not entirely clear who had seen the referral form. But the Council had and therefore it should have asked more questions of the Trust, at the conference, why the Trust’s views about previous alleged risks had so radically changed and in what way the risks had dissipated. That was important information which should have been available to the conference and which the Council should have sought;

The Chair also noted some discrepancy in the information provided but, according to the minutes, he too did not ask pertinent questions of the Trust as to why it was withdrawing its previous allegations. That too was a lost opportunity to question the Trust. However, this may have come about because the Chair had not seen the referral form and therefore was not fully aware of the significant change of approach by the Unit;

The Chair had the option of deferring a decision. Given that the Council referred to the conflicting health reports, and had wanted to carry out an assessment to clarify concerns, the option of deferring should have been explained to conference members.

In terms of injustice, but for the faults I consider that it is more likely than not the Council would have proceeded down the child in need route, particularly if the Consultant had provided information to the Social Worker in advance of the conference.

I consider that the faults have therefore led the Council to make a significant decision to commence child protection enquiries, ask Mr X to leave the family home and to threaten care proceedings. While the Council had the discretion to act in this way to protect Ms X, the reality was that she was not living at home, so the Council did not need to take immediate protective action and it could have sought more information first.

In respect of Child B, if as highlighted, information had been obtained from the Consultant of the Unit early on, I consider that, on the balance of probability, this would have prevented the need for Mr X to leave his home.

I find therefore that Mr and Mrs X and Ms X have suffered avoidable distress and harm, disruption to their family life, and have incurred unnecessary expenses.

Agreed actions

There is agreement that the following actions will be undertaken by the bodies in jurisdiction within three months of the date of the final decision:

To write to the parents and to Ms X apologising for the faults which I have highlighted;

To pay Mr and Mrs X’s unnecessary legal costs (subject to appropriate invoices), with the Trust paying half and the rest shared between the Council and the Hospital;

To make a payment to remedy the avoidable distress and harm caused to the family of £2000 in the same proportions as above. It will be for Mr and Mrs X to determine the proportion for Ms X;

To explain what steps will be taken to ensure their respective complaints procedures adequately reflect the need for, and enable, joint investigations;

To explain what steps will be taken to monitor who will carry out actions agreed at Care Programme Approach meetings and joint agency meetings, and by when.

The Trust has already brought in changes to its procedures because of this complaint. But, in addition, within three months of our decision, the Trust will:

Review its child protection procedures and tell the Ombudsmen whether it will require that safeguarding referrals for a child or young person detained in a mental health unit to be approved by the treating Consultant;

Ensure that, if the Trust makes a safeguarding referral to a local authority, it submits a written report for child protection conferences;

Devise a standard letter explaining the limits of confidentiality to those taking part in family therapy sessions and the circumstances when information might be disclosed;

Tell the Ombudsmen whether there is a way to restrict access to the content of family therapy sessions or to otherwise reassure those taking part that personal and sensitive information will be protected;

Revise its procedures to ensure that young people’s allegations about carers are referred directly to the LADO and, other complaints about the care provided, either from parents or young people, are dealt with promptly and in writing;

Produce a leaflet for young people about how their complaints will be dealt with;

Consider whether carers in mental health units could benefit from more training about safe and appropriate care for those with a mental health disorder.

The Hospital will within three months:

Consider issuing advice to staff about taking a pregnancy test for young people, explaining also when consent from parents may be required;

Consider whether additional training is required for its safeguarding advisors to ensure that reports for conferences accurately reflect the information available.

The Council

Suffolk Safeguarding Children’s Board may need to consider the Ombudsmen’s recommendations where they affect inter-agency working.

The Council will within three months:

Remind social workers of the importance of recording all contacts and of the need to have a prompt discussion, with the person making the safeguarding referral, which covers the areas of concerns so that the Council can better assess the evidence for the allegations early in the child protection enquiry;

Ensure safeguarding referral forms are disclosed to members of the conference and to the parents/carers, unless there is a reason why this would not be safe or appropriate;

Insist that agencies, making an initial safeguarding referral, submit a written report to the conference. It may be that the multi-agency referral form can state that this will be required;

The Council’s current protocol (April 2016) about conducting child protection enquiries for young people in hospitals refers to the need for social workers to consult the treating Consultant. It should be made clear that this applies equally to young people detained in a mental health setting;

Consider whether guidance should be issued about the use of ‘Working Agreements’. These can be successful in managing risk and safeguarding children and young people. But they must be proportionate and based on the Council having the evidence to justify, for example, asking a parent to leave their home. Parents/carers should also have the opportunity to challenge these agreements if they do not think they are proportionate or necessary;

Where a young person has been detained in a secure mental health setting on a section for 90 days, the Council will consider carrying out an assessment to see if there are additional services which can be provided under the child in need framework and in preparation of the Council’s aftercare duties once the young person is discharged to the community;

Consider whether young people, detained in mental health settings on a section, should formally be classified as disabled on the Council’s records;

Chairs of conferences will be reminded of the need to check that parents/carers have had reports within the required time;

While deferring a decision should not be used to avoid difficult decisions, Chairs will tell conference members that there is this option;

Consider whether it is appropriate to now appoint an independent advocate for Ms X, if she is willing to have one, to help her in next steps;

Consider, in discussion with Mr and Mrs X, whether they should receive support from an independent provider, with mental health expertise and with an awareness of the statutory aftercare responsibilities of agencies to assist them in the next stages of their daughter’s recovery;

The Council will pay £500 to Mr and Mrs X to recognise the avoidable distress and cost of asking Mr X to leave the family home.

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